BENEFIT ENROLLMENT / CHANGE FORM
You are required to sign and date this form before it can be processed. Please complete and return to HRM.
1.
TYPE OF ACTION REQUESTED: (Any changes must be submitted within 60 days of the qualifying event)
☐ New Enrollment ☐ Add Dependent(s) ☐ Other: (i.e., open enrollment)
☐ Health ☐ Dental ☐ Bo
th
Reason:
Reason:
☐ New Enrollment (Flex Cash) ☐ Delete Dependent(s) ☐ Cancel Health/Dental/Flex Cash
☐ Health ☐ Dental ☐ Both
Reason:
Reason:
(Please attach a copy of your medical and /or dental card to process your flex cash request)
☐ Previous Employment at this or other CSU Campus
C
ampus: Date of Employment:
2.
EMPLOYEE INFORMATION: (PLEASE PRINT OR TYPE)
Em
ployee Name:
SS#:
Address:
Street City State Zip Code
Ho
me Phone: (
) – Date of Birth: Hire Date:
Gender:
☐ Male ☐ Female
Marital Status:
☐ Married ☐ Single
Department:
Ext:
3.
DEPENDENT INFORMATION: Complete information for current and/or new dependents
To add a spouse or dom
estic partner for the first time, you must provide his/her social security number and the
Marriage Certificate or Domestic Partner Certification.
To add a child, you must provide the birth certificate and social security number. To add a child other than your
natural, adopted or stepchild, you must provide a notarized “Affidavit of Eligibility” form and copies of your tax
return showing this child is your tax dependent.
N
ame Relationship Date of Birth SS Number
Action
☐
Add ☐ Delete
☐ Add ☐ Delete
☐ Add ☐ Delete
☐ Add ☐ Delete
☐ Add ☐ Delete
4.
HEALTH PLAN (Choose One):
☐ An
them Blue Cros
s Select ☐ A
nthem Blue Cross Traditional ☐ Blue Sh
ield Access+
☐ Health Net Salud y Mas CA ☐ Health Net SmartCare CA ☐ Kaiser
☐ Blue Shield Trio
☐ Pers Care
☐ Pers Choice ☐ Pers Select ☐ PORAC
(Restricted to employees in Unit 8)
☐ Sharp Performance Plus CA
(Restricted to San Diego County) ☐ UnitedHealthCare Alliance CA
5.
DENTAL PLAN (Choose one):
☐ Delta Dental (DPO) ☐ DeltaCare (DMO)
(Facility Number*)
*If you do not select a Delta Care dentist, you will be automatically assigned to one closest to your home.
6.
PLEASE READ CAREFULLY AND SIGN BELOW
☐
I elect to E
NROLL OR CHANGE TO the Health Benefits Plan as shown above and authorize deductions to be made from
my salary or retirement allowance to cover my share of the cost of enrollment as it is now or as it may be in the future. I als
o
certify th
at the names of all dependents listed above are eligible family members as defined in the Public Employ
ees’
Med
ical and Hosp
ital Care Act.
☐
I DO N
OT wish to enroll in the Health Benefits Plan under the Public Employees’ Medical and
Hospital Care Act.
☐
I elect to CA
NCEL the Health Benefits Plan shown abov
e.
Employee or Annuitant’s Signature
Date Signed
California State University, Los Angeles | Human Resources Management
(8/20/2019)
